CurrentCentenePolicy CP.PHAR.458

Inebilizumab-cdon (Uplizna)

Clinical policy defining medical necessity criteria, initial and continued approval, contraindications, dosing, and coding for inebilizumab-cdon (Uplizna) for NMOSD (AQP4+ adults) and IgG4-related disease in adults across Commercial, HIM, and Medicaid lines of business.

Policy Summary

PayerCentene

PolicyInebilizumab-cdon (Uplizna)

Policy CodePolicy CP.PHAR.458

Change TypeMultiple clinical and coverage updates (added indications, concurrent therapy restrictions, approval duration change, step therapy bypass)

Effective DateJun 11, 2020

Next Review Date

Key ActionProvider must submit documentation (office notes, labs, etc.) supporting that member meets all approval criteria; prior authorization may be required for rituximab.

POLICY UPDATE CHANGES

Added Epysqli to the list of therapies that Uplizna should not be prescribed concurrently with for NMOSD.

Revised continued approval duration from 6 to 12 months for NMOSD.

Added criteria for the newly approved indication of IgG4-RD.

Added step therapy bypass for IL HIM per IL HB 5395.

Added Bkemv and Ultomiris to the list of therapies that Uplizna should not be prescribed concurrently with.

2FDA-approved indications covered

18+Minimum age

300 mgLoading dose